Occupational Medicine 2007;57:424–429
Published online 13 June 2007 doi:10.1093/occmed/kqm041

Peer responses to perceived stress in the
Royal Navy
Neil Greenberg1, Arthur Henderson2, Victoria Langston1, Amy Iversen1 and S. Wessely1
...................................................................................................................................................................................

Background Various organizations, including the Armed Forces, regularly place their personnel into potentially
traumatic environments. Exposure to such events can lead to the development of psychological
distress and organizational inefficiencies. It follows that the Armed Forces need to consider how
best to address and prevent trauma-related problems both from duty of care and organizational
effectiveness viewpoints.
...................................................................................................................................................................................

Aim

To investigate how Royal Navy personnel report they would deal with distress including the possibility of Deliberate Self-Harm (DSH) in peers.

...................................................................................................................................................................................

Methods

In total, 142 interview transcripts were examined to see how military personnel would respond to
a vignette which was concerned with how they would help a distressed peer. Interviews were analysed using content analysis and inclusive inductive categorization.

...................................................................................................................................................................................

Results

The majority of individuals would interact positively with a peer who appeared to be ‘under stress’,
and refer them on if problems did not resolve. Most respondents reported they would take positive
action regarding immediate management of DSH, referring to either medical or management staff.
The majority thought that reporting ideas of DSH would impact upon the potential harmer’s career.
Lower ranked personnel were more likely to report a negative impact.

...................................................................................................................................................................................

Conclusions The results are generally encouraging; the majority of those interviewed would actively involve
themselves in the care of their peers and refer them on appropriately if the situation deteriorated.
Most individuals interviewed saw DSH as a real, predominately medical problem that required
immediate active intervention. However, many felt that help seeking could be detrimental to one’s
career within the services.
...................................................................................................................................................................................

Key words

Armed Forces; deliberate self-harm; qualitative; stress.

...................................................................................................................................................................................

Introduction
The psychological impact of warfare was recognized in
Ancient Greece [1] and has been an incontrovertible issue since World War One [2]. Medical and lay attitudes to
distressed military personnel have varied and have often
viewed service personnel as weak or somehow deficient
should they be unable to withstand the horrors of war
[2,3]. However, it is currently accepted that exposure to
potentially traumatic events can result in short- and longterm psychological distress [4]. By virtue of their role, the
Armed Forces are at significant risk of suffering occupation-related distress. As they can never prevent exposing
1

KCMHR, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK.

2

King’s College London, School of Medicine, London, UK.

Correspondence to: Neil Greenberg, KCMHR, Weston Education Centre,
Cutcombe Road, London SE5 9RJ, UK. Tel: 144 207 848 5351; fax: 144 207
848 5408; e-mail: sososanta@aol.com

personnel to traumatic stressors, military commanders
need to find effective ways of managing them [4].
The Ministry of Defence (MoD), as with all organizations, has a legal duty of care towards its employees.
The issue was closely examined in the 2002 PostTraumatic Stress Disorder trial [5]. The case was found
in favour of the MoD; however, the MoD accepted that
Post-Traumatic Stress reactions were an ongoing organizational issue. Within the Royal Navy (RN), a peer-led
traumatic stress management strategy known as Trauma
Risk Management (TRiM) has been developed. TRiM
encourages peer support, education and monitoring of
individuals exposed to potentially traumatic events [4,6].
TRiM aims to engender cultural change towards an
environment not only better equipped to deal with the
psychological aftermath of traumatic events but also able
to highlight those requiring further support [4]. An ongoing randomized controlled trial (RCT) of TRiM is
assessing any changes in culture, occupational health

Ó The Author 2007. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

N. GREENBERG ET AL.: PEER RESPONSES TO PERCEIVED STRESS 425

functionality and psychological morbidity, after implementing the system.
Within both civilian and military settings, Deliberate
Self-Harm (DSH) is an important issue. According to the
National Institute of Clinical Excellence (NICE)
160 000 DSH cases present to Accident and Emergency (A&E) departments annually [7,8]; the lifetime
prevalence of DSH is 5% [9]. NICE state that physical
and psychological management must be immediate and
long term if psychological morbidity is suspected [10].
DSH in operational environments is especially problematic for leaders. Operational effectiveness, group morale
and cohesion must be maintained, while providing for the
individual’s needs in an often unsympathetic environment
[11]. A 2005 DSH audit in one RN psychiatric clinic
found that, similar to the civilian population, younger
personnel and females were especially at risk [12,13,8].
Although translating civilian statistics to military personnel requires caution, 25% of the general population
who DSH will repeat the act [8,13]. Also within civilian
settings irrespective of the severity of attempt (the degree
of injury or self-harm should not be used as an indicator
of intent [7]), those who DSH are at 50–100 times greater
risk of subsequent suicide [14]. DSH is strongly associated with a number of psychiatric conditions and a prior
psychiatric history is a notable civilian and military risk
factor [3,8]. The majority of DSH cases seen in A&E
departments meet criteria for at least one psychiatric diagnosis [15]; two-thirds as suffer from clinical depression
and one-half from a personality disorder [11]. Therefore,
DSH may herald other latent psychiatric conditions
which are incompatible with continued military service.
Both suicide and DSH are sensitive issues [16,17] and
the protection of the psychological well-being of service
personnel is as much a public relations issue as an occupational necessity. The very act of highlighting DSH as
a problem which requires ‘special’ solutions may generate
an issue from an act that would otherwise be easily manageable within a closed institution such as the services.
Although research statistics vary, it has been suggested
that the lifetime prevalence of suicidal or DSH ideation
may be 15–25% [18] [19] and may affect 5% of the population annually [16,20]. While Kuo et al. [21], in their
13-year prospective follow-up, conclude that ideation is
an important antecedent to a suicidal act (relative risk
of 6.09), it is evident that the majority of those with
self-harming thoughts do not self-harm. How those in
authority decide the point that self-harming thoughts in
themselves justify employability restrictions is unclear
and likely to vary depending of the nature of occupation.
Cultural issues play an important role in moderating
stress responses, both at an organizational and individual
level. The UK military encourages individuals to adopt
a resilient ‘stiff upper lip’ when faced with stressful circumstances, traumatic or otherwise [22]. As there are
considerable difficulties in measuring culture using quan-

titative methodologies, this study, part of the TRiM
RCT, used semi-structured interviews with vignette
questions about hypothetical scenarios. The qualitative
analysis did not aim to provide statistically valid estimates
of opinion or belief and the study’s value lies in gaining
a broader understanding of important issues [23].
The study aimed to examine attitudes, perceptions
and cultural beliefs within the RN towards mental illness
before TRiM implementation. The study also investigated how RN personnel might manage distressed peers
if they threatened DSH.

Methods
The TRiM RCT was designed to involve 12 warships. After baseline assessment, half the warships were scheduled
to receive TRiM training with effects assessed after 12–18
months as most RN personnel spend between 2 and 5 years
with one ship. Ethical approval was obtained from the MoD
(Navy) Personnel Research Ethics Committee. Stratified
sampling was used to ensure that the ranks of those interviewed were proportional to the range of ranks within any
particular vessel. Informed consent was gained from all participants; no personnel refused to be interviewed.
As part of the TRiM trial, baseline measurements
30–35 one-to-one structured interviews per vessel were
conducted. Rank selection was proportionally representative from Officers, Senior Ratings (SRs) and Junior
Ratings (JRs). Non-officers enter the service as JRs and
it takes a minimum of 5 years to become SRs. Promotion
is usually dependent on competitive selection.
The results concern responses to a vignette, presented
during one-to-one interviews with one of five researchers
(V.L., N.G., Paul Cawkill, S.W., Glynne Parsons). This
focused upon how interviewees might respond to perceived stress in a peer and consisted of five questions
(presented below).
All interviewers were well acquainted with the RN
and naval jargon to facilitate rapport with interviewees.
Voice recording was not used in order to increase interview compliance; interviewers transcribed all responses.
Qualitative analysis was undertaken by generating
categories derived inductively from the interview contents [8]. This gave rise to 15 to 20 loosely grouped
sub-categories. Decisions about the generated categories
and whether answers were positive or negative resulted
from team discussion, one of who was a military psychiatrist. Negative comments were ones thought not likely to
reduce distress levels or appeared ignorant of the potential risk of harm to distressed individuals. The analysis
was completed by refining themes by repeatedly indexing
responses into the following broader categories:
a) If you noticed one of your colleagues (of a similar rank/
rate) appearing vacant and not performing at work
what, if anything, would you do?

426 OCCUPATIONAL MEDICINE

Positive response
Negative response
b) If things appeared to be getting worse and whatever
you had tried above was not working and the person
was getting worse, what would you do then?
Refer on
Self manage
Nothing
c) What would you expect the outcome to be from a.
and b. above?
Advice given
Respite from work given
N/A
d) If the person told you that they had thought about
harming themselves, what would you do then?
Stop them
Refer to Medical staff
Refer to Management staff
Negative response
e) If they saw a doctor or psychiatric professional because
of their self-harming thoughts what effect do you think
that it would have on their long-term career?
Negative impact
No impact
Positive impact
Don’t know

Results
The group comprised of 142 individuals aged between
18 and 48 years old. This represented 38% of the total
number of interviews randomly selected from 11 warships. Respondents had been with their current unit
between 12 days and 84 months.
There were only a few negative or unhelpful responses
to the first vignette question concerning interviewees’
possible actions after noticing a colleague appearing
vacant and not performing at work. Between 96 and
98% of all ranks gave positive responses.
Responses to the second question concerning respondents possible actions if things appeared to be deteriorating
were divided into those service personnel who felt well
placed to continue managing the problem themselves
(20%, n 5 28) and those reporting that they would ask for
help from or pass the situation onto a senior (79%, n 5 112).
Differences in responses by rank are shown in Table 1.
When the responses were considered by rank, senior
ranks, Officers (42%) and SRs (23%) were more likely to
try and manage the problem themselves.
The results from the third question which enquired
about possible outcomes from interviewees’ first two
answers indicated generally positive outcomes; no
respondents indicated that the distressed individual
would be reprimanded. The majority were of the opinion
that their peer would receive advice from the consulted
senior (71%, n 5 101) (see Table 2).

Table 1. Responses, by rank, to Q. 2 concerning a colleague’s
emotional state which appeared to be getting worse
Rank

Refer on

Self manage

Do nothing

Officers
SRs
JRs

58% (n 5 14)
77% (n 5 37)
84% (n 5 59)

42% (n 5 10)
23% (n 5 11)
13% (n 5 9)

0
0
3% (n 5 2)

Table 2. Responses, by rank, to Q. 3 concerning the likely outcome of the help given to a distressed colleague
Rank

Give advice

Allow respite

Unsure

Officers
SRs
JRs

50% (n 5 12)
77% (n 5 37)
74% (n 5 52)

42% (n 5 10)
17% (n 5 8)
23% (n 5 16)

8% (n 5 2)
6% (n 5 3)
3% (n 5 2)

The remainder suggested that distressed peers would
be given some form of respite from work or duties (24%,
n 5 34). Officers tended to favour their distressed peers
receiving respite (50%) while non-officers thought advice
would be more appropriate (75%, n 5 89).
The responses to the question concerning possible
actions following being told that a peer had thought about
harming themselves were divided between those who assumed the DSH act was imminent and those who thought
it was likely. Thus, several answers followed the notion
‘stop them, then go and get help’; such responses were
recorded into both the ‘Stop’ and ‘Medical/Management’
categories. This section gave rise to 182 comments in total.
The majority (95%, n 5 173) of comments were positive. Officers (36%) were more likely to refer to senior
managers (often the Commanding Officer or the Executive officer the second in command) than SRs (17%) or
JRs (27%). Only a small number of negative comments
were reported, most by JRs (7%) (see Table 3).
The final question about the potential career implications of asking for help with self-harming thoughts
provided the most divided response. Though a significant
number were unsure of the consequences (14%, n 5 20)
and few proposed positive outcomes (3%, n 5 4), the
majority were split between ‘no impact’ (41%, n 5 58)
and a ‘negative impact’ (43%, n 5 61) upon their peer’s
career. Examining the answers by rank revealed that JRs
were substantially more likely to suggest negative outcome (56%) than either Officers (29%, n 5 7) or SRs
(29%, n 5 14) (see Table 4).
Examples of qualitative comments for each question
can be found in Table 5.

Discussion
The results show the majority of respondents reported
they would respond positively and appropriately towards

N. GREENBERG ET AL.: PEER RESPONSES TO PERCEIVED STRESS 427

Table 3. Responses, by rank, to Q. 4 concerning actions that might be taken if a peer reported that they had thought of self-harming
Rank

Stop them

Medical referral

Management referral

Negative action

Officers
SRs
JRs

21% (n 5 7)
19% (n 5 11)
18% (n 5 16)

40% (n 5 13)
60% (n 5 35)
48% (n 5 44)

36% (n 5 12)
17% (n 5 10)
27% (n 5 25)

3% (n 5 1)
3% (n 5 2)
7% (n 5 6)

Table 4. Responses, by rank, to Q. 5 concerning the possible career impact of seeking professional help for thoughts of self-harm
Rank

Unsure

Positive impact

No effect

Negative impact

Officers
SRs
JRs

13% (n 5 3)
15% (n 5 7)
14% (n 5 10)

4% (n 5 1)
6% (n 5 3)
0

54% (n 5 13)
50% (n 5 24)
30% (n 5 21)

29% (n 5 7)
29% (n 5 14)
56% (n 5 39)

Table 5. Qualitative examples of comments expressed by respondents
Question

Type

Comment examples

1. If you noticed one of your colleagues (of a similar
rank/rate) appearing vacant and not performing
at work what, if anything, would you do?

Positive

Approach them, have a chat, find out their problems
I would have a word with EWO (executive warrant
officer—most experienced SR onboard)
Not my responsibility
I would tell him to sort himself out, you know get on
with it
I would inform MO (Medical Officer, a fully trained
registered doctor)
Would mention it to boss/Divisional Officer
(line manager)
Go and see peers, on the quiet, looking after each
other
Take a bit of work off them
I would probably distance myself from them
Give good advice
MO (Medical Officer) would have a chat with them,
offer support
Get time off or reduce workload
I would try and talk them out of it
Inform Medical Officer
Inform the Military police
Go and get OOD (officer of the day—duty officer)
Laugh it off and tell them not to be so stupid
Might avoid the subject
I don’t think they would ever return to frontline
service
People would stay away from them and not include
them in anything
Nothing. Everything would be done medical in
confidence therefore they would get better
I would hope that . . . better able to deal with
stress as they would have been taught how to cope
with things and do things better
It may depend upon how much it has affected them
psychologically and if there are any consequences in
terms of performance

Negative

2. If things appeared to be getting worse and
whatever you had tried above was not working
and the person was getting worse, what would
you do then?

Refer

Self manage

3. What would you expect the outcome to be from
the questions above?

4. If the person told you that they had thought about
harming themselves, what would you do then?

Do nothing
Advice

Respite
Stop them
Medical
Management
Negative

5. If they saw a doctor or psychiatric professional
because of their self-harming thoughts what
effect do you think that it would have on their
long-term career?

Negative

No impact
Positive

Don’t know

distressed peers. Most interviewees would appropriately
refer the more serious cases to senior officers or medical
personnel; however, such positive action was not uni-

versal. Less than half of those interviewed thought that
receiving support in relation to thoughts of self-harm
would be detrimental to an individual’s long-term career.

428 OCCUPATIONAL MEDICINE

Qualitative methods, while allowing for an endless
range of responses, may be subject to the Hawthorne
Effect; that is to say that overly positive responses may
have been given in order that respondents appeared
acceptable to the interviewer. Also interviews cannot distinguish between the possible reactions towards likeable
peers rather than peers who are disliked. Qualitative
methodology does not allow for valid statistical comparisons between groups in the same way that quantitative
studies would do as a result of methodology and sample
size. Therefore, although rank groupings are proportionally correct, it was not possible to be certain that differences found between ranks groups were statistically valid.
Finding that the majority of individuals would signpost
appropriately distressed peers reflects the finding of
Greenberg et al. [22] that 98% of UK peacekeepers spoke
informally about operational stress to friends or peers.
This is perhaps not surprising as peers are well placed
to provide emotional and functional support to distressed
colleagues whose usual coping mechanisms are overwhelmed. Peer support has been shown to be of substantial benefit to those subject to the effects of excessive
pressure [24].
Faced with a persistently distressed peer, the majority
of junior personnel favoured referring the problem to
someone senior. This is particularly relevant as previous
studies have shown that within UK military junior ranks
are especially vulnerable to developing mental health
problems [25]. Our finding differs from those of Cawkill
et al. [26] who argued that not only were military individuals reluctant to self-disclose but also Armed Forces
personnel felt little support was available from peers or
commanders. This maybe because Cawkill’s study examined the expectations of distressed individuals, who are
more pessimistic about the support that would be available for them; Hoge et al. [27] have shown that an important barrier to the receipt of care is the fear of being
stigmatized, particularly among those who are unwell.
Many respondents reported that those referred would
generally receive either appropriate advice or respite from
duties. Our finding that non-officers favoured advice
while officers favoured respite most probably arose from
differences in service experience, training and authority
as much as attitudes. Most respondents did not indicate
that receiving help would have any immediate career
implications.
Like the RN, resilient organizations may view stress
negatively with sufferers being labelled as weak [28] or
unsuitable for responsibility [10]. Stigmatization may
also occur [15]. Our findings though suggest that distressed employees should not fear seeking help from
those around them as it likely they will receive appropriate care.
When a peer mentioned that they may harm themselves swift action was again the predominant response.
Our results showed that, irrespective of rank, those aware

of potential DSH favoured referring the issue to more
appropriate sources of support, usually managers or
medical staff [7].
The Armed Forces are not alone in requiring robust
individuals to perform in exceptionally difficult circumstances. The emergency services, the diplomatic service
and many media organizations share similar needs. Research suggests that employees in such organizations are
at risk of psychological problems while deployed [29,30]
Our findings are therefore likely to be of relevance to such
organizations, especially so where personnel cannot readily access UK style healthcare and instead rely on peers
and managers for support.
The Health & Safety Executive recognize that the
availability of workplace support and the nature of workplace relationships are important factors which must be
managed to minimize stress at work. Our results would
suggest that interventions aimed at ensuring that more
junior staff members know what to do about distress in
others may be especially useful. Local, and therefore
more accessible, support may also decrease the stigma
of asking for assistance from medical or mental health
providers which is a considerable barrier to care for many.
Inevitably, a small proportion of distressed employees will
require professional help; however, this study indicates
that peers are willing to refer on such cases. The notion
of mess camaraderie has always been strong within the
RN ensuring that ships were ready to wage war and our
results suggest that comradeship may be just as useful for
battling psychological difficulties.

Key points
• Most RN personnel would deal with distressed
colleagues in an appropriate and positive manner
and did not report stigmatizing beliefs concerning
mental health issues.
• Junior personnel were less positive about the impact on an individual’s career should help be requested because someone was intending to harm
themselves.
• Peer-led support may be an acceptable and effective way of initial management of distressed employees especially in organizations that favour
resilience.

Conflicts of interest
None declared.

References
1. Marlowe D. Psychological and Psychosocial Consequences of
Combat and Deployment: with Special Emphasis on the Gulf

N. GREENBERG ET AL.: PEER RESPONSES TO PERCEIVED STRESS 429

2.

3.

4.

5.

6.

7.
8.

9.

10.
11.

12.
13.

14.
15.

16.
17.

War. Santa Monica, CA: National Defence Research Institute, RAND, 2001.
Wessely S, Jones E. Shell Shock to PTSD: Military Psychiatry
from 1900 to the Gulf War (Maudsley Monographs). New
York: Psychology Press, 2005.
Young A. The Harmony of Illusions: Inventing Post-Traumatic
Stress Disorder. Princeton, NJ: Princeton University Press,
1997.
Greenberg N, Cawkill P, March C, Sharpley J. How to
TRiM away at post traumatic stress reactions: traumatic
risk management—now and the future. J R Nav Med Serv
2005;91:26–31.
Applegate D. Lessons Learnt from the PTSD Group Action,
Service Personnel Board. A Paper by the Stress Project Leader.
London: MOD, 2003.
Jones N, Roberts P, Greenberg N. Peer-group risk assessment: a post-traumatic management strategy for hierarchical organizations. Occup Med (Lond) 2003;53:469–475.
Yeo H. The cost of treatment of deliberate self-harm. Arch
Emerg Med 1993;10:8–14.
Pope C, Ziebland S, Mays N. Qualitative research in
healthcare. Analysing qualitative data. Br Med J 2000;320:
114–116.
Meltzer H, Lader D, Corbin T, Singleton N, Jenkins R,
Brugha T. Non-Fatal Suicidal Behaviour among Adults aged
16 to 74 in Great Britain. London: The Stationery Office,
2002.
Schneider R, Luscomb R. Battle stress reaction and the
United States Army. Mil Med 1984;149:66–69.
PLAGO 0102 (Officers and Ratings—Deliberate Self Harm or
Suicide). Naval Life Management Division. Royal Navy,
2006; 1–30.
Micklewright S. Deliberate self harm in the Royal Navy.
J R Nav Med Serv 2005;91:12–25.
Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry 2003;182:
537–542.
Porter T, Johnson W. Psychiatric stigma in the military. Mil
Med 1994;159:602–605.
Hawton K, Williams K. The connection between the media and suicidal behaviour warrants serious attention. Crisis
2001;22:137–140.
BBC. The Deepcut Investigations. http://news.bbc.co.uk/1/
hi/uk/3179985.stm (20 May 2006, date last accessed).
Nicholas Blake QC. Statement by Mr Nicholas Blake QC to
the Deepcut & Beyond Group on 7th June 2005. http://news.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

bbc.co.uk/1/shared/bsp/hi/pdfs/04_11_05_deepcut_blake.
pdf (20 May 2007, date last accessed).
De Leo D, Cerin E, Spathonis K, Burgis S. Lifetime risk of
suicide ideation and attempts in an Australian community:
prevalence, suicidal process, and help-seeking behaviour.
J Affect Disord 2005;86:215–224.
´
Botega N, Barros M, Oliveira H, Dalgalarrondo P, Marın´
Leon L. Suicidal behavior in the community: prevalence
and factors associated with suicidal ideation. Rev Bras Psiquiatr 2005;27:45–53.
Goldney R, Wilson D, Dal Grande E, Fisher L, McFarlane
A. Suicidal ideation in a random community sample: attributable risk due to depression and psychosocial and
traumatic events. Aust N Z J Psychiatry 2000;34:98–106.
Kuo W, Gallo J, Tien A. Incidence of suicide ideation and
attempts in adults: the 13-year follow-up of a community
sample in Baltimore, Maryland. Psychol Med 2001;31:
1181–1191.
Greenberg N, Maingay S, Iverson A et al. Perceived psychological support of UK military peacekeepers on return
from deployment. J Ment Health 2003;6:565–573.
National Institute of Clinical Evidence (NICE). PostTraumatic Stress Disorder (PTSD): The Management of
PTSD in Adults and Children in Primary and Secondary Care.
London: 2005.
Cohen S, Sherrod D, Clark M. Social skills and the stressprotective role of social support. J Pers Soc Psychol 1986;50:
963–973.
Ismail K, Blatchley N, Hotopf M et al. Occupational
risk factors for ill health in Gulf veterans of the United
Kingdom. J Epidemiol Community Health 2000;54:834–838.
Cawkill P. A study into commanders’ understanding of,
and attitudes to, stress and stress-related problems. J R
Army Med Corps 2004;150:91–96.
Hoge C, Castro C, Messer S, McGurk D, Cotting D, Koffman R. Combat duty in Iraq and Afghanistan, mental
health problems, and barriers to care. N Engl J Med
2004;351:13–22.
Harvey J. Stress: Attitudes and Experiences of British
Army Personnel. DRA Report No. DRA/LS3/CR96103/1.0.
Hampshire: Defence Research Agency, 1996.
Feinstein A, Owen J, Blair N. A hazardous profession: war,
journalists, and psychopathology. Am J Psychiatry 2002;
159:1570–1575.
Patel D, Easmon C, Dow C, Snashall D, Seed PT. Medical
repatriation of British diplomats resident overseas. J Travel
Med 2000;7:64–69.